About this role
Job summary
The Frailty Coordinator will be responsible for managing the care of people registered with Malling PCN practices, a particular focus on residents living with frailty supporting the Single Neighbourhood Health Service, a new model of care for patients with the most complex needs across Kent and Medway.The Frailty Coordinator will work closely with colleagues in this GP lead service to manage a caseload of patients. The Frailty Coordinator may also provide some basic clinical care within their own competency and deliver health interventions where trained and competent .A key part of the role will be improving the continuity of care by acting as a point of contact for patients, GP practices, MDT meetings and community nursing staff in the management of our patients in PNG* 10 and 11 (*Patient Need Groups) paying particular attention to the completion of the patients Comprehensive Geriatric Assessment. A CGA evaluates the whole person and creates an individualized care plan aimed at maintaining independence, health, and quality of life.The Frailty Coordinator will review patients needs and help them access the services and support they require. Initiate discussions around ReSPECT forms and wishes surrounding care particularly if the patient is unable to make decisions for themselves.Patient in PNG groups 10 & 11 are both ambulatory and housebound, the Frailty Care Coordinator will be expected to assist colleagues with both cohorts within the groups.
Main duties of the job
Provide a point of contact for patients, practices, Clinical Assessment Home Visiting Team and community nursing staff to support collaborative working in the delivery of proactive care of patients in PNG groups 10 & 11.
To ensure up to date CGAs are in place for housebound patients and arrange reviews as required.
Initiate discussions with patients, outlining the ReSPECT form and the desire to involve the patient in how and where they would like to be cared for, and what would happen to them if they became unwell and unable to make a decision.
To support prompt reconciliation and review of medication for patients following discharge from hospital.
Consult with patients and their families for medical history, to undertake a CGA and future care wishes where required.
Schedule MDT meetings, manage the meeting agenda items; ensuring that all new referrals are identified, and information circulated to team members as required.
Use a range of tools provided to assess and record information relating to health needs and care required.
Provide support to Clinical Assessment Home Visiting Team as required.
Provide coordination and navigation for people and their carers across health and care, working closely with other primary care professionals, helping to ensure patients the most appropriate care and support.
Support the coordination and delivery of multidisciplinary teams with the PCN.
About us
Primary Care Networks (PCNs) were formed in 2019 as a key part of the NHS Long Term Plan. The aim of the networks is to provide the structure and funding for services to be developed locally, in response to the needs of the patients they serve. Our PCN is formed of five local practices: West Malling Group Practice, Thornhills Medical Practice, Snodland Medical Practice, Wateringbury Surgery and The Phoenix Surgery and serves a combined population of about 60,000.
Malling PCN is CQC registered.
Job description Job responsibilities
Some of the expected duties are set out below but these will vary depending on the current needs and priorities of the PCN.
Key responsibilities
Provide a point of contact for patients, practices, Clinical Assessment Home Visiting Team and community nursing staff to support collaborative working in the delivery of proactive care of patients in PNG groups 10 & 11.
To ensure up to date CGAs are in place for housebound patients and arrange reviews as required.
Initiate discussions with patients, outlining the ReSPECT form and the desire to involve the patient in how and where they would like to be cared for, and what would happen to them if they became unwell and unable to make a decision.
To support prompt reconciliation and review of medication for patients following discharge from hospital.
Consult with patients and their families for medical history, to undertake a CGA and future care wishes where required.
Schedule MDT meetings, manage the meeting agenda items; ensuring that all new referrals are identified, and information circulated to team members as required.
Receive and collate information from transfers of care including hospital admissions and discharges plus out of hours calls and present this information to the MDT as required.
Use a range of tools provided to assess and record information relating to health needs and care required.
Provide support to Clinical Assessment Home Visiting Team as required.
Provide coordination and navigation for people and their carers across health and care, working closely with other primary care professionals, helping to ensure patients the most appropriate care and support.
Support the coordination and delivery of multidisciplinary teams with the PCN.
Help people to manage their needs through answering queries, making and managing appointments, and ensuring that people have good quality written or verbal information to help them make choices about their care.
Work collaboratively with GPs and other primary care professionals within the PCN to proactively identify and manage a caseload, which may include patients with long-term health conditions, and where appropriate, refer to other health professionals within the PCN.
Raise awareness of how to identify patients who may benefit from shared decision making and support PCN staff and patients to be more prepared to have shared decision-making conversations.
Support PCNs in developing communication channels between GPs, people and their families and carers and other agencies;
Conduct follow-ups on communications from out of hospital and in-patient services.
Maintain accurate clinical care records to include all referrals and interventions.
Support practices to keep care records up-to-date by identifying and updating missing or out-of-date information about the persons circumstances.
Contribute to risk and impact assessments, monitoring and development of the service.
ADDITIONAL RESPONSIBILITIES
Ensures guidance for recording activity is adhered to in collaboration with other team members.
Completes clear documentation of CGA and personalised care plan on GP systems.
Accurate update and maintenance of GP systems within the MDT.
To provide agreed performance/activity data relating to activity of frailty team.
Demonstrates ability to work as a member of a team.
Recognises personal limitations and refer to appropriate colleagues when necessary.
Actively work towards developing and maintaining effective working relationships both within and outside the PCN.
Liaises with other stakeholders as needed for the collective benefit of patients.
Develop excellent working relationships with the partners, wider service networks including the voluntary sector, GP practices, adult social care, hospitals, community pharmacists and other members of the MDT.
Provides information to patients, their carers and/or relatives.
Communicate effectively with service users and their families/carers, other staff both internal and external and members of the public.
Acts always in an anti-discriminatory manner.
WORKING RELATIONSHIPS
Although focused on practice-based work, the role will require regular interface with other professionals to promote greater integration of the PCN in the wider community setting including,
Patients
GPs, nurses, and other practice staff
PCN Clinical Director and the PCN management team
Wider Frailty teams including GP leads from each practice, Care home Coordinator, Care home Pharmacists, Physician Associate, Paramedic Visiting teams.
Other healthcare professionals involved in medicines management team including the ICB Medicines Management Team
GP prescribing leads in practices
Community nurses and other allied health professionals including dietetics.
Community pharmacists and support staff
Hospital staff with responsibilities for prescribing and medicines optimisation
Care Home staff where required
Person Specification
Qualifications Essential
Care Certificate / NMTS/NVQ Level 2 or 3 in Health and Social Care , minimum requirement Demonstrable commitment to professional and personal development Ability to use Microsoft Office applications Word, Excel, PowerPoint, Outlook Ability and experience using clinical systems ie EMIS
Desirable
NVQ Level 3 in adult care - advanced level or equivalent qualifications or working towards
Experience Essential
Ability to actively listen, empathise with people and provide personalised support in a non-judgemental way Ability to provide a culturally sensitive service supporting people from all backgrounds and communities, respecting lifestyles and diversity Commitment to reducing health inequalities and proactively working to reach people from diverse communities Ability to support people in a way that inspires trust and confidence, motivating others to reach their potential Ability to communicate effectively, both verbally and in writing, with people, their families, carers, community groups, partner agencies and stakeholders Have a strong awareness and understanding of when it is appropriate or necessary to refer people back to other health professionals/agencies, when what the person needs is beyond the scope of the care coordinator role e.g. when there is a mental health need requiring a qualified practitioner Ability to maintain effective working relationships and to promote collaborative practice with all colleagues Knowledge of, and ability to work to policies and procedures, including confidentiality, safeguarding, lone working, information governance, and health and safety. Willingness to work flexible hours when required to meet work demands Access to own transport. Ability to travel across the locality on a regular basis
Desirable
Ability to provide motivational coaching to support peoples behaviour change Experience of working directly in a care coordinator role, adult health and social care, learning support or public health / health improvement Experience or training in personalised care and support planning Experience of working with elderly or vulnerable people, complying with best practice and relevant legislation Knowledge of Safeguarding Children and Vulnerable Adults policies and processes Basic knowledge of long term conditions and the complexities involved: medical, physical, emotional and social
Disclosure and Barring Service Check This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service (formerly known as CRB) to check for any previous criminal convictions.
Employer details Employer name Malling PCN
Address Lyndean House
30-32 Albion Place
Maidstone
Kent
ME14 5Dz
United Kingdom
Employer's website https://www.mallingpcn.co.uk/ (Opens in a new tab)